Illinois General Assembly - Full Text of SB0471
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Full Text of SB0471  102nd General Assembly




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1    AN ACT concerning regulation.
2    Be it enacted by the People of the State of Illinois,
3represented in the General Assembly:
4    Section 5. The Network Adequacy and Transparency Act is
5amended by changing Section 10 as follows:
6    (215 ILCS 124/10)
7    Sec. 10. Network adequacy.
8    (a) An insurer providing a network plan shall file a
9description of all of the following with the Director:
10        (1) The written policies and procedures for adding
11    providers to meet patient needs based on increases in the
12    number of beneficiaries, changes in the
13    patient-to-provider ratio, changes in medical and health
14    care capabilities, and increased demand for services.
15        (2) The written policies and procedures for making
16    referrals within and outside the network.
17        (3) The written policies and procedures on how the
18    network plan will provide 24-hour, 7-day per week access
19    to network-affiliated primary care, emergency services,
20    and woman's principal health care providers.
21    An insurer shall not prohibit a preferred provider from
22discussing any specific or all treatment options with
23beneficiaries irrespective of the insurer's position on those



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1treatment options or from advocating on behalf of
2beneficiaries within the utilization review, grievance, or
3appeals processes established by the insurer in accordance
4with any rights or remedies available under applicable State
5or federal law.
6    (b) Insurers must file for review a description of the
7services to be offered through a network plan. The description
8shall include all of the following:
9        (1) A geographic map of the area proposed to be served
10    by the plan by county service area and zip code, including
11    marked locations for preferred providers.
12        (2) As deemed necessary by the Department, the names,
13    addresses, phone numbers, and specialties of the providers
14    who have entered into preferred provider agreements under
15    the network plan.
16        (3) The number of beneficiaries anticipated to be
17    covered by the network plan.
18        (4) An Internet website and toll-free telephone number
19    for beneficiaries and prospective beneficiaries to access
20    current and accurate lists of preferred providers,
21    additional information about the plan, as well as any
22    other information required by Department rule.
23        (5) A description of how health care services to be
24    rendered under the network plan are reasonably accessible
25    and available to beneficiaries. The description shall
26    address all of the following:



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1            (A) the type of health care services to be
2        provided by the network plan;
3            (B) the ratio of physicians and other providers to
4        beneficiaries, by specialty and including primary care
5        physicians and facility-based physicians when
6        applicable under the contract, necessary to meet the
7        health care needs and service demands of the currently
8        enrolled population;
9            (C) the travel and distance standards for plan
10        beneficiaries in county service areas; and
11            (D) a description of how the use of telemedicine,
12        telehealth, or mobile care services may be used to
13        partially meet the network adequacy standards, if
14        applicable.
15        (6) A provision ensuring that whenever a beneficiary
16    has made a good faith effort, as evidenced by accessing
17    the provider directory, calling the network plan, and
18    calling the provider, to utilize preferred providers for a
19    covered service and it is determined the insurer does not
20    have the appropriate preferred providers due to
21    insufficient number, type, or unreasonable travel distance
22    or delay, the insurer shall ensure, directly or
23    indirectly, by terms contained in the payer contract, that
24    the beneficiary will be provided the covered service at no
25    greater cost to the beneficiary than if the service had
26    been provided by a preferred provider. This paragraph (6)



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1    does not apply to: (A) a beneficiary who willfully chooses
2    to access a non-preferred provider for health care
3    services available through the panel of preferred
4    providers, or (B) a beneficiary enrolled in a health
5    maintenance organization. In these circumstances, the
6    contractual requirements for non-preferred provider
7    reimbursements shall apply.
8        (7) A provision that the beneficiary shall receive
9    emergency care coverage such that payment for this
10    coverage is not dependent upon whether the emergency
11    services are performed by a preferred or non-preferred
12    provider and the coverage shall be at the same benefit
13    level as if the service or treatment had been rendered by a
14    preferred provider. For purposes of this paragraph (7),
15    "the same benefit level" means that the beneficiary is
16    provided the covered service at no greater cost to the
17    beneficiary than if the service had been provided by a
18    preferred provider.
19        (8) A limitation that, if the plan provides that the
20    beneficiary will incur a penalty for failing to
21    pre-certify inpatient hospital treatment, the penalty may
22    not exceed $1,000 per occurrence in addition to the plan
23    cost sharing provisions.
24    (c) The network plan shall demonstrate to the Director a
25minimum ratio of providers to plan beneficiaries as required
26by the Department.



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1        (1) The ratio of physicians or other providers to plan
2    beneficiaries shall be established annually by the
3    Department in consultation with the Department of Public
4    Health based upon the guidance from the federal Centers
5    for Medicare and Medicaid Services. The Department shall
6    not establish ratios for vision or dental providers who
7    provide services under dental-specific or vision-specific
8    benefits. The Department shall consider establishing
9    ratios for the following physicians or other providers:
10            (A) Primary Care;
11            (B) Pediatrics;
12            (C) Cardiology;
13            (D) Gastroenterology;
14            (E) General Surgery;
15            (F) Neurology;
16            (G) OB/GYN;
17            (H) Oncology/Radiation;
18            (I) Ophthalmology;
19            (J) Urology;
20            (K) Behavioral Health;
21            (L) Allergy/Immunology;
22            (M) Chiropractic;
23            (N) Dermatology;
24            (O) Endocrinology;
25            (P) Ears, Nose, and Throat (ENT)/Otolaryngology;
26            (Q) Infectious Disease;



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1            (R) Nephrology;
2            (S) Neurosurgery;
3            (T) Orthopedic Surgery;
4            (U) Physiatry/Rehabilitative;
5            (V) Plastic Surgery;
6            (W) Pulmonary;
7            (X) Rheumatology;
8            (Y) Anesthesiology;
9            (Z) Pain Medicine;
10            (AA) Pediatric Specialty Services;
11            (BB) Outpatient Dialysis; and
12            (CC) HIV.
13        (2) The Director shall establish a process for the
14    review of the adequacy of these standards, along with an
15    assessment of additional specialties to be included in the
16    list under this subsection (c).
17    (d) The network plan shall demonstrate to the Director
18maximum travel and distance standards for plan beneficiaries,
19which shall be established annually by the Department in
20consultation with the Department of Public Health based upon
21the guidance from the federal Centers for Medicare and
22Medicaid Services. These standards shall consist of the
23maximum minutes or miles to be traveled by a plan beneficiary
24for each county type, such as large counties, metro counties,
25or rural counties as defined by Department rule.
26    The maximum travel time and distance standards must



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1include standards for each physician and other provider
2category listed for which ratios have been established.
3    The Director shall establish a process for the review of
4the adequacy of these standards along with an assessment of
5additional specialties to be included in the list under this
6subsection (d).
7    (d-5) (1) Every insurer shall ensure that beneficiaries
8have timely and proximate access to treatment for mental,
9emotional, nervous, or substance use disorders or conditions
10in accordance with the provisions of paragraph (4) of
11subsection (a) of Section 370c of the Illinois Insurance Code.
12Insurers shall use a comparable process, strategy, evidentiary
13standard, and other factors in the development and application
14of the network adequacy standards for timely and proximate
15access to treatment for mental, emotional, nervous, or
16substance use disorders or conditions and those for the access
17to treatment for medical and surgical conditions. As such, the
18network adequacy standards for timely and proximate access
19shall equally be applied to treatment facilities and providers
20for mental, emotional, nervous, or substance use disorders or
21conditions and specialists providing medical or surgical
22benefits pursuant to the parity requirements of Section 370c.1
23of the Illinois Insurance Code and the federal Paul Wellstone
24and Pete Domenici Mental Health Parity and Addiction Equity
25Act of 2008. Notwithstanding the foregoing, the network
26adequacy standards for timely and proximate access to



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1treatment for mental, emotional, nervous, or substance use
2disorders or conditions shall, at a minimum, satisfy the
3following requirements:
4            (A) For beneficiaries residing in the metropolitan
5        counties of Cook, DuPage, Kane, Lake, McHenry, and
6        Will, network adequacy standards for timely and
7        proximate access to treatment for mental, emotional,
8        nervous, or substance use disorders or conditions
9        means a beneficiary shall not have to travel longer
10        than 30 minutes or 30 miles from the beneficiary's
11        residence to receive outpatient treatment for mental,
12        emotional, nervous, or substance use disorders or
13        conditions. Beneficiaries shall not be required to
14        wait longer than 10 business days between requesting
15        an initial appointment and being seen by the facility
16        or provider of mental, emotional, nervous, or
17        substance use disorders or conditions for outpatient
18        treatment or to wait longer than 20 business days
19        between requesting a repeat or follow-up appointment
20        and being seen by the facility or provider of mental,
21        emotional, nervous, or substance use disorders or
22        conditions for outpatient treatment; however, subject
23        to the protections of paragraph (3) of this
24        subsection, a network plan shall not be held
25        responsible if the beneficiary or provider voluntarily
26        chooses to schedule an appointment outside of these



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1        required time frames.
2            (B) For beneficiaries residing in Illinois
3        counties other than those counties listed in
4        subparagraph (A) of this paragraph, network adequacy
5        standards for timely and proximate access to treatment
6        for mental, emotional, nervous, or substance use
7        disorders or conditions means a beneficiary shall not
8        have to travel longer than 60 minutes or 60 miles from
9        the beneficiary's residence to receive outpatient
10        treatment for mental, emotional, nervous, or substance
11        use disorders or conditions. Beneficiaries shall not
12        be required to wait longer than 10 business days
13        between requesting an initial appointment and being
14        seen by the facility or provider of mental, emotional,
15        nervous, or substance use disorders or conditions for
16        outpatient treatment or to wait longer than 20
17        business days between requesting a repeat or follow-up
18        appointment and being seen by the facility or provider
19        of mental, emotional, nervous, or substance use
20        disorders or conditions for outpatient treatment;
21        however, subject to the protections of paragraph (3)
22        of this subsection, a network plan shall not be held
23        responsible if the beneficiary or provider voluntarily
24        chooses to schedule an appointment outside of these
25        required time frames.
26        (2) For beneficiaries residing in all Illinois



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1    counties, network adequacy standards for timely and
2    proximate access to treatment for mental, emotional,
3    nervous, or substance use disorders or conditions means a
4    beneficiary shall not have to travel longer than 60
5    minutes or 60 miles from the beneficiary's residence to
6    receive inpatient or residential treatment for mental,
7    emotional, nervous, or substance use disorders or
8    conditions.
9        (3) If there is no in-network facility or provider
10    available for a beneficiary to receive timely and
11    proximate access to treatment for mental, emotional,
12    nervous, or substance use disorders or conditions in
13    accordance with the network adequacy standards outlined in
14    this subsection, the insurer shall provide necessary
15    exceptions to its network to ensure admission and
16    treatment with a provider or at a treatment facility in
17    accordance with the network adequacy standards in this
18    subsection.
19    (e) Except for network plans solely offered as a group
20health plan, these ratio and time and distance standards apply
21to the lowest cost-sharing tier of any tiered network.
22    (f) The network plan may consider use of other health care
23service delivery options, such as telemedicine or telehealth,
24mobile clinics, and centers of excellence, or other ways of
25delivering care to partially meet the requirements set under
26this Section.



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1    (g) Except for the requirements set forth in subsection
2(d-5), insurers Insurers who are not able to comply with the
3provider ratios and time and distance standards established by
4the Department may request an exception to these requirements
5from the Department. The Department may grant an exception in
6the following circumstances:
7        (1) if no providers or facilities meet the specific
8    time and distance standard in a specific service area and
9    the insurer (i) discloses information on the distance and
10    travel time points that beneficiaries would have to travel
11    beyond the required criterion to reach the next closest
12    contracted provider outside of the service area and (ii)
13    provides contact information, including names, addresses,
14    and phone numbers for the next closest contracted provider
15    or facility;
16        (2) if patterns of care in the service area do not
17    support the need for the requested number of provider or
18    facility type and the insurer provides data on local
19    patterns of care, such as claims data, referral patterns,
20    or local provider interviews, indicating where the
21    beneficiaries currently seek this type of care or where
22    the physicians currently refer beneficiaries, or both; or
23        (3) other circumstances deemed appropriate by the
24    Department consistent with the requirements of this Act.
25    (h) Insurers are required to report to the Director any
26material change to an approved network plan within 15 days



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1after the change occurs and any change that would result in
2failure to meet the requirements of this Act. Upon notice from
3the insurer, the Director shall reevaluate the network plan's
4compliance with the network adequacy and transparency
5standards of this Act.
6(Source: P.A. 100-502, eff. 9-15-17; 100-601, eff. 6-29-18.)
7    Section 10. The Illinois Public Aid Code is amended by
8changing Sections 5-16.8 and 5-30.1 as follows:
9    (305 ILCS 5/5-16.8)
10    Sec. 5-16.8. Required health benefits. The medical
11assistance program shall (i) provide the post-mastectomy care
12benefits required to be covered by a policy of accident and
13health insurance under Section 356t and the coverage required
14under Sections 356g.5, 356u, 356w, 356x, 356z.6, 356z.26,
15356z.29, 356z.32, 356z.33, 356z.34, and 356z.35 of the
16Illinois Insurance Code, and (ii) be subject to the provisions
17of Sections 356z.19, 364.01, 370c, and 370c.1 of the Illinois
18Insurance Code, and (iii) be subject to the provisions of
19subsection (d-5) of Section 10 of the Network Adequacy and
20Transparency Act.
21    The Department, by rule, shall adopt a model similar to
22the requirements of Section 356z.39 of the Illinois Insurance
24    On and after July 1, 2012, the Department shall reduce any



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1rate of reimbursement for services or other payments or alter
2any methodologies authorized by this Code to reduce any rate
3of reimbursement for services or other payments in accordance
4with Section 5-5e.
5    To ensure full access to the benefits set forth in this
6Section, on and after January 1, 2016, the Department shall
7ensure that provider and hospital reimbursement for
8post-mastectomy care benefits required under this Section are
9no lower than the Medicare reimbursement rate.
10(Source: P.A. 100-138, eff. 8-18-17; 100-863, eff. 8-14-18;
11100-1057, eff. 1-1-19; 100-1102, eff. 1-1-19; 101-81, eff.
127-12-19; 101-218, eff. 1-1-20; 101-281, eff. 1-1-20; 101-371,
13eff. 1-1-20; 101-574, eff. 1-1-20; 101-649, eff. 7-7-20.)
14    (305 ILCS 5/5-30.1)
15    Sec. 5-30.1. Managed care protections.
16    (a) As used in this Section:
17    "Managed care organization" or "MCO" means any entity
18which contracts with the Department to provide services where
19payment for medical services is made on a capitated basis.
20    "Emergency services" include:
21        (1) emergency services, as defined by Section 10 of
22    the Managed Care Reform and Patient Rights Act;
23        (2) emergency medical screening examinations, as
24    defined by Section 10 of the Managed Care Reform and
25    Patient Rights Act;



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1        (3) post-stabilization medical services, as defined by
2    Section 10 of the Managed Care Reform and Patient Rights
3    Act; and
4        (4) emergency medical conditions, as defined by
5    Section 10 of the Managed Care Reform and Patient Rights
6    Act.
7    (b) As provided by Section 5-16.12, managed care
8organizations are subject to the provisions of the Managed
9Care Reform and Patient Rights Act.
10    (c) An MCO shall pay any provider of emergency services
11that does not have in effect a contract with the contracted
12Medicaid MCO. The default rate of reimbursement shall be the
13rate paid under Illinois Medicaid fee-for-service program
14methodology, including all policy adjusters, including but not
15limited to Medicaid High Volume Adjustments, Medicaid
16Percentage Adjustments, Outpatient High Volume Adjustments,
17and all outlier add-on adjustments to the extent such
18adjustments are incorporated in the development of the
19applicable MCO capitated rates.
20    (d) An MCO shall pay for all post-stabilization services
21as a covered service in any of the following situations:
22        (1) the MCO authorized such services;
23        (2) such services were administered to maintain the
24    enrollee's stabilized condition within one hour after a
25    request to the MCO for authorization of further
26    post-stabilization services;



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1        (3) the MCO did not respond to a request to authorize
2    such services within one hour;
3        (4) the MCO could not be contacted; or
4        (5) the MCO and the treating provider, if the treating
5    provider is a non-affiliated provider, could not reach an
6    agreement concerning the enrollee's care and an affiliated
7    provider was unavailable for a consultation, in which case
8    the MCO must pay for such services rendered by the
9    treating non-affiliated provider until an affiliated
10    provider was reached and either concurred with the
11    treating non-affiliated provider's plan of care or assumed
12    responsibility for the enrollee's care. Such payment shall
13    be made at the default rate of reimbursement paid under
14    Illinois Medicaid fee-for-service program methodology,
15    including all policy adjusters, including but not limited
16    to Medicaid High Volume Adjustments, Medicaid Percentage
17    Adjustments, Outpatient High Volume Adjustments and all
18    outlier add-on adjustments to the extent that such
19    adjustments are incorporated in the development of the
20    applicable MCO capitated rates.
21    (e) The following requirements apply to MCOs in
22determining payment for all emergency services:
23        (1) MCOs shall not impose any requirements for prior
24    approval of emergency services.
25        (2) The MCO shall cover emergency services provided to
26    enrollees who are temporarily away from their residence



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1    and outside the contracting area to the extent that the
2    enrollees would be entitled to the emergency services if
3    they still were within the contracting area.
4        (3) The MCO shall have no obligation to cover medical
5    services provided on an emergency basis that are not
6    covered services under the contract.
7        (4) The MCO shall not condition coverage for emergency
8    services on the treating provider notifying the MCO of the
9    enrollee's screening and treatment within 10 days after
10    presentation for emergency services.
11        (5) The determination of the attending emergency
12    physician, or the provider actually treating the enrollee,
13    of whether an enrollee is sufficiently stabilized for
14    discharge or transfer to another facility, shall be
15    binding on the MCO. The MCO shall cover emergency services
16    for all enrollees whether the emergency services are
17    provided by an affiliated or non-affiliated provider.
18        (6) The MCO's financial responsibility for
19    post-stabilization care services it has not pre-approved
20    ends when:
21            (A) a plan physician with privileges at the
22        treating hospital assumes responsibility for the
23        enrollee's care;
24            (B) a plan physician assumes responsibility for
25        the enrollee's care through transfer;
26            (C) a contracting entity representative and the



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1        treating physician reach an agreement concerning the
2        enrollee's care; or
3            (D) the enrollee is discharged.
4    (f) Network adequacy and transparency.
5        (1) The Department shall:
6            (A) ensure that an adequate provider network is in
7        place, taking into consideration health professional
8        shortage areas and medically underserved areas;
9            (B) publicly release an explanation of its process
10        for analyzing network adequacy;
11            (C) periodically ensure that an MCO continues to
12        have an adequate network in place; and
13            (D) require MCOs, including Medicaid Managed Care
14        Entities as defined in Section 5-30.2, to meet
15        provider directory requirements under Section 5-30.3;
16        and .
17            (E) require MCOs, including Medicaid Managed Care
18        Entities as defined in Section 5-30.2, to meet each of
19        the requirements under subsection (d-5) of Section 10
20        of the Network Adequacy and Transparency Act; with
21        necessary exceptions to the MCO's network to ensure
22        that admission and treatment with a provider or at a
23        treatment facility in accordance with the network
24        adequacy standards in paragraph (3) of subsection
25        (d-5) of Section 10 of the Network Adequacy and
26        Transparency Act is limited to providers or facilities



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1        that are Medicaid certified.
2        (2) Each MCO shall confirm its receipt of information
3    submitted specific to physician or dentist additions or
4    physician or dentist deletions from the MCO's provider
5    network within 3 days after receiving all required
6    information from contracted physicians or dentists, and
7    electronic physician and dental directories must be
8    updated consistent with current rules as published by the
9    Centers for Medicare and Medicaid Services or its
10    successor agency.
11    (g) Timely payment of claims.
12        (1) The MCO shall pay a claim within 30 days of
13    receiving a claim that contains all the essential
14    information needed to adjudicate the claim.
15        (2) The MCO shall notify the billing party of its
16    inability to adjudicate a claim within 30 days of
17    receiving that claim.
18        (3) The MCO shall pay a penalty that is at least equal
19    to the timely payment interest penalty imposed under
20    Section 368a of the Illinois Insurance Code for any claims
21    not timely paid.
22            (A) When an MCO is required to pay a timely payment
23        interest penalty to a provider, the MCO must calculate
24        and pay the timely payment interest penalty that is
25        due to the provider within 30 days after the payment of
26        the claim. In no event shall a provider be required to



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1        request or apply for payment of any owed timely
2        payment interest penalties.
3            (B) Such payments shall be reported separately
4        from the claim payment for services rendered to the
5        MCO's enrollee and clearly identified as interest
6        payments.
7        (4)(A) The Department shall require MCOs to expedite
8    payments to providers identified on the Department's
9    expedited provider list, determined in accordance with 89
10    Ill. Adm. Code 140.71(b), on a schedule at least as
11    frequently as the providers are paid under the
12    Department's fee-for-service expedited provider schedule.
13        (B) Compliance with the expedited provider requirement
14    may be satisfied by an MCO through the use of a Periodic
15    Interim Payment (PIP) program that has been mutually
16    agreed to and documented between the MCO and the provider,
17    and the PIP program ensures that any expedited provider
18    receives regular and periodic payments based on prior
19    period payment experience from that MCO. Total payments
20    under the PIP program may be reconciled against future PIP
21    payments on a schedule mutually agreed to between the MCO
22    and the provider.
23        (C) The Department shall share at least monthly its
24    expedited provider list and the frequency with which it
25    pays providers on the expedited list.
26    (g-5) Recognizing that the rapid transformation of the



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1Illinois Medicaid program may have unintended operational
2challenges for both payers and providers:
3        (1) in no instance shall a medically necessary covered
4    service rendered in good faith, based upon eligibility
5    information documented by the provider, be denied coverage
6    or diminished in payment amount if the eligibility or
7    coverage information available at the time the service was
8    rendered is later found to be inaccurate in the assignment
9    of coverage responsibility between MCOs or the
10    fee-for-service system, except for instances when an
11    individual is deemed to have not been eligible for
12    coverage under the Illinois Medicaid program; and
13        (2) the Department shall, by December 31, 2016, adopt
14    rules establishing policies that shall be included in the
15    Medicaid managed care policy and procedures manual
16    addressing payment resolutions in situations in which a
17    provider renders services based upon information obtained
18    after verifying a patient's eligibility and coverage plan
19    through either the Department's current enrollment system
20    or a system operated by the coverage plan identified by
21    the patient presenting for services:
22            (A) such medically necessary covered services
23        shall be considered rendered in good faith;
24            (B) such policies and procedures shall be
25        developed in consultation with industry
26        representatives of the Medicaid managed care health



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1        plans and representatives of provider associations
2        representing the majority of providers within the
3        identified provider industry; and
4            (C) such rules shall be published for a review and
5        comment period of no less than 30 days on the
6        Department's website with final rules remaining
7        available on the Department's website.
8    The rules on payment resolutions shall include, but not be
9limited to:
10        (A) the extension of the timely filing period;
11        (B) retroactive prior authorizations; and
12        (C) guaranteed minimum payment rate of no less than
13    the current, as of the date of service, fee-for-service
14    rate, plus all applicable add-ons, when the resulting
15    service relationship is out of network.
16    The rules shall be applicable for both MCO coverage and
17fee-for-service coverage.
18    If the fee-for-service system is ultimately determined to
19have been responsible for coverage on the date of service, the
20Department shall provide for an extended period for claims
21submission outside the standard timely filing requirements.
22    (g-6) MCO Performance Metrics Report.
23        (1) The Department shall publish, on at least a
24    quarterly basis, each MCO's operational performance,
25    including, but not limited to, the following categories of
26    metrics:



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1            (A) claims payment, including timeliness and
2        accuracy;
3            (B) prior authorizations;
4            (C) grievance and appeals;
5            (D) utilization statistics;
6            (E) provider disputes;
7            (F) provider credentialing; and
8            (G) member and provider customer service.
9        (2) The Department shall ensure that the metrics
10    report is accessible to providers online by January 1,
11    2017.
12        (3) The metrics shall be developed in consultation
13    with industry representatives of the Medicaid managed care
14    health plans and representatives of associations
15    representing the majority of providers within the
16    identified industry.
17        (4) Metrics shall be defined and incorporated into the
18    applicable Managed Care Policy Manual issued by the
19    Department.
20    (g-7) MCO claims processing and performance analysis. In
21order to monitor MCO payments to hospital providers, pursuant
22to this amendatory Act of the 100th General Assembly, the
23Department shall post an analysis of MCO claims processing and
24payment performance on its website every 6 months. Such
25analysis shall include a review and evaluation of a
26representative sample of hospital claims that are rejected and



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1denied for clean and unclean claims and the top 5 reasons for
2such actions and timeliness of claims adjudication, which
3identifies the percentage of claims adjudicated within 30, 60,
490, and over 90 days, and the dollar amounts associated with
5those claims. The Department shall post the contracted claims
6report required by HealthChoice Illinois on its website every
73 months.
8    (g-8) Dispute resolution process. The Department shall
9maintain a provider complaint portal through which a provider
10can submit to the Department unresolved disputes with an MCO.
11An unresolved dispute means an MCO's decision that denies in
12whole or in part a claim for reimbursement to a provider for
13health care services rendered by the provider to an enrollee
14of the MCO with which the provider disagrees. Disputes shall
15not be submitted to the portal until the provider has availed
16itself of the MCO's internal dispute resolution process.
17Disputes that are submitted to the MCO internal dispute
18resolution process may be submitted to the Department of
19Healthcare and Family Services' complaint portal no sooner
20than 30 days after submitting to the MCO's internal process
21and not later than 30 days after the unsatisfactory resolution
22of the internal MCO process or 60 days after submitting the
23dispute to the MCO internal process. Multiple claim disputes
24involving the same MCO may be submitted in one complaint,
25regardless of whether the claims are for different enrollees,
26when the specific reason for non-payment of the claims



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1involves a common question of fact or policy. Within 10
2business days of receipt of a complaint, the Department shall
3present such disputes to the appropriate MCO, which shall then
4have 30 days to issue its written proposal to resolve the
5dispute. The Department may grant one 30-day extension of this
6time frame to one of the parties to resolve the dispute. If the
7dispute remains unresolved at the end of this time frame or the
8provider is not satisfied with the MCO's written proposal to
9resolve the dispute, the provider may, within 30 days, request
10the Department to review the dispute and make a final
11determination. Within 30 days of the request for Department
12review of the dispute, both the provider and the MCO shall
13present all relevant information to the Department for
14resolution and make individuals with knowledge of the issues
15available to the Department for further inquiry if needed.
16Within 30 days of receiving the relevant information on the
17dispute, or the lapse of the period for submitting such
18information, the Department shall issue a written decision on
19the dispute based on contractual terms between the provider
20and the MCO, contractual terms between the MCO and the
21Department of Healthcare and Family Services and applicable
22Medicaid policy. The decision of the Department shall be
23final. By January 1, 2020, the Department shall establish by
24rule further details of this dispute resolution process.
25Disputes between MCOs and providers presented to the
26Department for resolution are not contested cases, as defined



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1in Section 1-30 of the Illinois Administrative Procedure Act,
2conferring any right to an administrative hearing.
3    (g-9)(1) The Department shall publish annually on its
4website a report on the calculation of each managed care
5organization's medical loss ratio showing the following:
6        (A) Premium revenue, with appropriate adjustments.
7        (B) Benefit expense, setting forth the aggregate
8    amount spent for the following:
9            (i) Direct paid claims.
10            (ii) Subcapitation payments.
11            (iii) Other claim payments.
12            (iv) Direct reserves.
13            (v) Gross recoveries.
14            (vi) Expenses for activities that improve health
15        care quality as allowed by the Department.
16    (2) The medical loss ratio shall be calculated consistent
17with federal law and regulation following a claims runout
18period determined by the Department.
19    (g-10)(1) "Liability effective date" means the date on
20which an MCO becomes responsible for payment for medically
21necessary and covered services rendered by a provider to one
22of its enrollees in accordance with the contract terms between
23the MCO and the provider. The liability effective date shall
24be the later of:
25        (A) The execution date of a network participation
26    contract agreement.



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1        (B) The date the provider or its representative
2    submits to the MCO the complete and accurate standardized
3    roster form for the provider in the format approved by the
4    Department.
5        (C) The provider effective date contained within the
6    Department's provider enrollment subsystem within the
7    Illinois Medicaid Program Advanced Cloud Technology
8    (IMPACT) System.
9    (2) The standardized roster form may be submitted to the
10MCO at the same time that the provider submits an enrollment
11application to the Department through IMPACT.
12    (3) By October 1, 2019, the Department shall require all
13MCOs to update their provider directory with information for
14new practitioners of existing contracted providers within 30
15days of receipt of a complete and accurate standardized roster
16template in the format approved by the Department provided
17that the provider is effective in the Department's provider
18enrollment subsystem within the IMPACT system. Such provider
19directory shall be readily accessible for purposes of
20selecting an approved health care provider and comply with all
21other federal and State requirements.
22    (g-11) The Department shall work with relevant
23stakeholders on the development of operational guidelines to
24enhance and improve operational performance of Illinois'
25Medicaid managed care program, including, but not limited to,
26improving provider billing practices, reducing claim



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1rejections and inappropriate payment denials, and
2standardizing processes, procedures, definitions, and response
3timelines, with the goal of reducing provider and MCO
4administrative burdens and conflict. The Department shall
5include a report on the progress of these program improvements
6and other topics in its Fiscal Year 2020 annual report to the
7General Assembly.
8    (h) The Department shall not expand mandatory MCO
9enrollment into new counties beyond those counties already
10designated by the Department as of June 1, 2014 for the
11individuals whose eligibility for medical assistance is not
12the seniors or people with disabilities population until the
13Department provides an opportunity for accountable care
14entities and MCOs to participate in such newly designated
16    (i) The requirements of this Section apply to contracts
17with accountable care entities and MCOs entered into, amended,
18or renewed after June 16, 2014 (the effective date of Public
19Act 98-651).
20    (j) Health care information released to managed care
21organizations. A health care provider shall release to a
22Medicaid managed care organization, upon request, and subject
23to the Health Insurance Portability and Accountability Act of
241996 and any other law applicable to the release of health
25information, the health care information of the MCO's
26enrollee, if the enrollee has completed and signed a general



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1release form that grants to the health care provider
2permission to release the recipient's health care information
3to the recipient's insurance carrier.
4(Source: P.A. 100-201, eff. 8-18-17; 100-580, eff. 3-12-18;
5100-587, eff. 6-4-18; 101-209, eff. 8-5-19.)